Pott-y language

It was 3:00 a.m., and it was my first night shift on inpatient medicine as a third
year. I sat on the edge of my chair in the resident call room, anxiously awaiting
the next page from the ED alerting my intern of a new admission. “Beep beep
beep!”

This patient was an otherwise healthy young man who had emigrated from Somalia to
the U.S. 14 years ago. He was admitted for a 6-week history of dry cough, severe chest
and back pain, and shortness of breath. He also described having a flu-like illness
with fevers, drenching night sweats, and a 17-pound unintentional weight loss. A chest
CT from the referring hospital revealed a massive right-sided pleural effusion, ground-glass
infiltrates at bilateral lung apices, spondylosis of his T5-T9 vertebrae with an associated
thoracic paraspinal abscess, and multiple splenic lesions suggestive of granulomas.
Labs revealed elevated alkaline phosphatase levels with normal bilirubin and aminotransferase
levels, hypoalbuminemia, and normal renal function. Urinalysis was abnormal with many
dysmorphic red blood cells and proteinuria. Acid-fast sputum stain was positive, and
disseminated tuberculosis was diagnosed.

Illustration by David Rosenman

I was on with Dr. Newman, so I knew that I had better be prepared for both a clinical
discussion and a historic one.

Tuberculosis with spinal involvement is often referred to as Pott's disease, in honor
of the historic 18th-century surgeon Percivall Pott, who first described its clinical
presentation in the medical literature. Percivall Pott was born into humble beginnings
in London, England, in the early 1700s, suffering the loss of his father at a young
age. A wealthy distant relative financed his apprenticeship and tutelage under the
surgeon Edward Nourse at St. Bartholomew's Hospital. Dr. Pott aided in the preparation
of cadavers for public dissection and studied surgical technique under Dr. Nourse,
eventually opening his own surgical practice in 1736. He took a position as an assistant
surgeon in 1744 and had become one of the best surgeons of his time when he was appointed
to serve as a full surgeon at St. Bartholomew's in 1749.

In 1756, Dr. Pott suffered a compound fracture of his fibula and tibia after being
thrown from his horse on his way to work one morning. His surgical colleagues insisted
that his leg needed to be amputated, but Dr. Nourse was able to nonsurgically reduce
the fracture, which eventually fully healed without any further intervention. Dr.
Pott's path to recovery was quite lengthy, and some might argue this was a blessing
in disguise, as he penned many hallmark contributions to the medical literature during
this period in his life.

“A Treatise on Ruptures,” published in 1756, described the cause and
treatment of hernias, and “Observations on the Nature and Consequences of Wounds
and Contusions of the Head, Fractures of the Skull, Concussions of the Brain,”
published in 1760, covered traumatic skull and brain injuries. In 1765, Dr. Pott discussed
what would become the standard methods for treating fractures and dislocations in
“Some Few General Remarks on Fractures and Dislocations,” including
a description of what we call Pott's fracture, which is a much milder injury than
the one he himself suffered.

Perhaps one of Dr. Pott's most seminal contributions was his work on tracing the cause
of a type of cancer back to a specific hazardous exposure associated with one's occupation.
In 18th-century London, many young boys worked as chimney sweeps, climbing through
chimney flues to clean out blocked soot, which was a dangerous and often life-threatening
job in itself. However, many of these boys began to develop squamous-cell carcinoma
of the scrotum in their teens and 20s due to chronic exposure of the scrotal skin
to carcinogenic compounds in coal soot. This was the first time anyone had introduced
the public health concept of an occupational cancer.

In “Remarks on the Kind of Palsy of the Lower Limbs, Which Is Frequently Found
To Accompany a Curvature of the Spine,” published in 1779, Dr. Pott described
the clinical manifestations of extrapulmonary tuberculosis of the spine. He carefully
depicted the collapsed vertebrae and resultant curvature of the spine but did not
understand how this caused the eventual paralysis and neurologic sequelae.

Pott's disease is a life-threatening condition, even with advances in medical treatment,
due to this potential for neurologic compromise. Tuberculosis infection of the spine
is the most common manifestation of extrapulmonary tuberculosis, although it occurs
in fewer than 1% of overall patients with tuberculosis, according to studies in the
March 2001 Neurosurgery Review and the August 1995 Journal of Neurosurgery. Tuberculosis is a serious public health problem in Somalia. In a national 2011 survey
published in Emerging Infectious Diseases, multidrug-resistant tuberculosis was found in 5.2% and 40.8% of patients in Somalia
with new and previously treated disease, respectively.

Our patient was later found to have additional lesions in his S1 vertebrae, but no
further abdominopelvic involvement was found on CT. He was started on the standard
treatment regimen for spinal tuberculosis (rifampin, isoniazid, pyrazinamide, and
ethambutol), with pending antibiotic sensitivities, and is currently being evaluated
by our neurosurgery colleagues to determine the need for a thoraco-lumbar sacral orthosis
(TLSO) brace to prevent vertebral collapse secondary to his Pott's disease and potential
drainage of his paraspinal abscess.

Ms. Fracica is a third-year medical student at Mayo Medical School. Dr. Newman is
a hospitalist at Mayo Clinic in Rochester, Minn., and the editorial advisor and humor
columnist for ACP Hospitalist.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.